Influence of Insulin Resistance Status on the Development of Gallstones Following Roux-En-Y Gastric Bypass: a Prospective Cohort Study.

BACKGROUND: The occurrence of gallstones following Roux-en-Y gastric bypass (RYGB) has been extensively reported. As RYGB promotes improvement in insulin resistance (IR), which is one of the factors enrolled in the pathophysiology of gallstones, this study aims to determine the influence of IR and its post-RYGB course on the development of gallstones. METHODS: This is a prospective cohort study that enrolled 108 morbidly obese subjects free of gallstones which underwent RYGB and were followed up for 24 months, through clinical, laboratory, and ultrasound examinations. IR was assessed through the surrogate marker homeostasis model assessment (HOMA). RESULTS: Of the individuals evaluated, 29 (26.8%) developed gallstones following RYGB. In the univariate analysis, postsurgical gallstones were associated with preoperative HOMA (p < 0.0001), preoperative fasting glucose (p = 0.0019), preoperative fasting insulin (p = 0.0001), and preoperative triglycerides (p = 0.0001). Multivariate analysis revealed that preoperative HOMA was the only factor independently associated with gallstones (p < 0.0001). The incidence of gallstones among individuals with IR was 46.8%; in the non-IR subjects, the incidence was 7.4% (p < 0.0001). Preoperative IR led to a relative risk of 6.02 (95% CI = 2.1-17.3; p = 0.0009) of gallstones. CONCLUSIONS: As gallstones often occur following RYGB, there is controversy regarding their management. Some authors propose systematic cholecystectomy along with RYGB, while others suggest that the aggregate risk of the concomitant approach is significantly higher. As IR was a significant risk factor in this study, an individualized approach for this population may be proposed. Further research is needed to confirm these findings.

Obstructive Gastric Pseudotumor Caused by Cytomegalovirus in an AIDS Patient: A Case Report and Review of Surgical Treatment.

BACKGROUND: Cytomegalovirus (CMV) is a common opportunistic pathogen in patients with HIV. It is also a major cause of gastrointestinal ulcers in patients with acquired immunodeficiency syndrome (AIDS). CMV pseudotumor in the stomach is a rare cause of digestive tract obstruction. CASE REPORT: In this study we report a male patient infected with HIV in 2002. In 2014 he evolved C3 stage AIDS with pre-pyloric gastric ulcer which provoked deformity and pseudotumoral aspect of the gastric outlet. Endoscopic biopsy confirmed CMV infection. He underwent Roux-en-Y gastroenteroanastomosis with good recovery. CONCLUSIONS: CMV infection should be considered as an agent in gastric lesions in HIV-infected patients. Roux-en-Y gastroenteroanastomosis is a surgical option for this group of patients, allowing improvements in quality of life and decreasing risks of perioperative complications.

Megaduodenum associated with gastric strongyloidiasis.

Gastric strongyloidiasis and megaduodenum are rare diseases. Gastrointestinal (GI) strongyloidiasis has many clinical features. One of them is megaduodenum. We describe a case of a 32-years-old man who has come to us from an endemic area for Strongyloides stercoralis. He had had megaduodenum diagnosed in his childhood. We submitted him to two surgeries. He has recovered just after the second surgery, a Roux-en-Y partial gastrectomy. After that, his follow-up was uneventful and the patient has gained 10kg in weight. Histopathology confirmed gastric strongyloidiasis. In conclusion, if patients arrive from an endemic area of S. stercoralis and if they present GI symptoms or a previous diagnosis of megaduodenum, they must be considered for a histological evaluation for gastric strongyloidiasis.